Activeforever Pride Lift Chair Specialty Collection LC310 - Manual

U.S. DEPARTMENT OF HEALTH & HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0679
CERTIFICATE OF MEDICAL NECESSITY DMERC 07.02A
SEAT LIFT MECHANISM
SECTION A Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___
PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER
(__ __ __) __ __ __ - __ __ __ __ HICN
SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER
(__ __ __) __ __ __ - __ __ __ __ NSC #
PLACE OF SERVICE PT DOB ____/____/____; Sex ____ (M/F) ; HT.______(in.) ; WT._____(lbs.)
480 767-6800 N/A
NAME and ADDRESS of FACILITY if applicable (See PHYSICIAN NAME, ADDRESS (Printed or Typed)
HCPCS CODE:
SECTION B
Information in this Section May Not Be Completed by the Supplier of the Items/Supplies.
EST. LENGTH OF NEED (# OF MONTHS): ______ 1-99 (99=LIFETIME) DIAGNOSIS CODES (ICD-9):
ANSWERS ANSWER QUESTIONS 1 -5 FOR SEAT LIFT MECHANISM
(Circle
Y
for Yes,
N
for No, or
D
for Does Not Apply)
Y N D 1. Does the patient have severe arthritis of the hip or knee?
Y N D 2. Does the patient have a severe neuromuscular disease?
Y N D 3. Is the patient completely incapable of standing up from a regular armchair or any chair in his/her home?
Y N D 4. Once standing, does the patient have the ability to ambulate?
Y N D 5. Have all appropriate therapeutic modalities to enable the patient to transfer from a chair to a standing position
(e.g., medication, physical therapy) been tried and failed? If YES, this is documented in the patient's medical records.
NAME OF PERSON ANSWERING SECTION B QUESTIONS, IF OTHER THAN PHYSICIAN (Please Print):
NAME: TITLE: EMPLOYER:
SECTION C Narrative Description Of Equipment And Cost
(1) Narrative description of all items, accessories and options ordered; (2) Supplier's charge; and (3) Medicare Fee Schedule
Allowance for each item, accessory, and option. (See Instructions On Back)
SECTION D Physician Attestation and Signature/Date
I certify that I am the physician identified in Section A of this form. I have received Sections A, B and C of the Certificate of Medical Necessity (including charges
for items ordered). Any statement on my letterhead attached hereto, has been reviewed and signed by me. I certify that the medical necessity information in
Section B is true, accurate and complete, to the best of my knowledge, and I understand that any falsification, omission, or concealment of material fact in that
section may subject me to civil or criminal liability.
PHYSICIAN'S SIGNATURE
DATE / / (SIGNATURE AND DATE STAMPS ARE NOT ACCEPTABLE)
CMS 849 (04/96)
Reverse)
PHYSICIAN'S UPIN:
PHYSICIAN'S TELEPHONE #: (__ __ __) __ __ __- __ __ __ __
ActiveForever
10799 N. 90th St.
Scottsdale, AZ 85260
E062__nu